In Pharmacy Vaccination Consent Form and Scheduler Only

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Name* This field is required.
First Name
Last Name
Suffix
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Appointment* This field is required.
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Gender* This field is required.
Male
Female
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Phone Number* This field is required.
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Email* This field is required.
example@example.com
8
MEDICARE Number (Red White and Blue Card)* This field is required.11 digit alpanumeric, no dashes needed. If you are not over 65, type NA
9
Insurance Information (Complete fields below or upload a picture of your card below):If you do NOT have any insurance, please write "NO INSURANCE" below and complete the last field.
10
Insurance Card File Upload
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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11
Which vaccine(s) are you getting?Please note Influenza and COVID vaccines are recommended and can be administered at the same time
2024-25 Influenza Vaccine
NEW Moderna COVID-19 Booster (Spikevax)
NEW Pfizer COVID-19 Booster (Comirnarty)
Respiratory Syncytial Virus Vaccine (RSV)
PREVNAR-20 Pneumonia Vaccine
SHINGRIX shingles Vaccine
TDaP
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Potential Contraindications/Considerations* This field is required.
Yes
No
Not Sure
Are you feeling sick today
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Have you ever had a severe allergic reaction (e.g. anaphylaxis) in the past? Example, a reaction in which you were treated with epinephrine or Epipen, or for which you had to go to the hospital?
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- Was the severe allergic reaction after receiving a COVID-19 or Influenza Vaccine?
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- Was the severe reaction after receiving another vaccine or injectable medication?
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- Was the severe allergic reaction related to receiving Polyethylene Glycol or products containing Polyethylene Glycol (eg Miralax)?
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- Was the severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
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Have you received any monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?
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If you have had COVID-19, are you symptom free?
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Do you have a bleeding disorder?
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Do you have an allergy to eggs (flu vaccine only)?
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Have you ever had Guillain-Barré syndrome?
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For women, are you currently pregnant or breastfeeding?
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Are you feeling sick today
Have you ever had a severe allergic reaction (e.g. anaphylaxis) in the past? Example, a reaction in which you were treated with epinephrine or Epipen, or for which you had to go to the hospital?
- Was the severe allergic reaction after receiving a COVID-19 or Influenza Vaccine?
- Was the severe reaction after receiving another vaccine or injectable medication?
- Was the severe allergic reaction related to receiving Polyethylene Glycol or products containing Polyethylene Glycol (eg Miralax)?
- Was the severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
Have you received any monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?
If you have had COVID-19, are you symptom free?
Do you have a bleeding disorder?
Do you have an allergy to eggs (flu vaccine only)?
Have you ever had Guillain-Barré syndrome?
For women, are you currently pregnant or breastfeeding?
Yes
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No
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Not Sure
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Yes
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No
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Not Sure
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Yes
Row 2, Column 0
No
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Not Sure
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Yes
Row 3, Column 0
No
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Not Sure
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Yes
Row 4, Column 0
No
Row 4, Column 1
Not Sure
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Not Sure
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Not Sure
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
Not Sure
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Yes
Row 8, Column 0
No
Row 8, Column 1
Not Sure
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Yes
Row 9, Column 0
No
Row 9, Column 1
Not Sure
Row 9, Column 2
Yes
Row 10, Column 0
No
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Not Sure
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Yes
Row 11, Column 0
No
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Not Sure
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Terms and Conditions* This field is required.
14
Signature of Patient (or authorized representative)* This field is required.
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